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Definition

The destructive operations are designed to

diminish the bulk of the fetus so as to

facilitate easy delivery through the birth

canal.
Types

Craniotomy

Evisceration

Decapitation

Cleidotomy

Symphysiotomy
For all destructive operations
Preliminaries:
Either general or local anesthesia is used.
Position: LITHOTOMY position.
Full surgical asepsis has to be followed.
Ask the mother to empty her bladder.
Vaginal examination has to be done.
CRANIOTOMY
Definition:

It is an operation to make a perforation

on the fetal head to evacuate the contents followed

by extraction of the fetus.


Indications:

• Cephalic presentation producing obstructed labor

with dead fetus.

• Hydrocephalus even in a living fetus.

• Interlocking head of twins.


 Conditions to be fulfilled:

 The cervix must be fully dilated.

Baby must be dead (Hydrocephalus excluded).

 Contraindication

 When the pelvis is severely contracted.

 Rupture of uterus where laparotomy is essential


Instrument

OLDHAM’S PERFORATOR
Sites of perforation:

Vertex - On the parietal bone either side of the

sagittal suture

Face -Through the orbit or hard palate

Brow -Through the frontal bone


Procedure:

ACTUAL STEPS:

Step 1:

Introduce two fingers into the vagina (index and


middle).

Do incision through the suture line or dependent


part.
Cont.,.,

Step 2:

 Introduce the Oldham’s perforator with the


blades closed is introduced through the birth canal
up to the site of perforation & apply it
perpendicular to it.
Cont.,.,

Step 3

By rotating movements perforate the skull is


rotated.

During this step, an assistant is asked to steady


the head per abdomen in manner of 1st pelvic
grip.
Cont.,.,

Step 4:

Evacuate the brain matter with the fingers.

 After the delivery of the placenta, the utero-


vaginal canal must be explored as a routine for
any exposure of rupture uterus or any tear.
DECAPITATION
Definition:

It is a destructive operation whereby the

fetal head is severed from the trunk and the

delivery is completed with the extraction of the

trunk and that of the decapitated head per


Indication:

Neglected shoulder presentation with dead fetus

where neck is easily accessible.

Interlocking head of twins.


Instrument

DECAPITATED HOOK
Procedure:

ACTUAL STEPS:

 Step 1:

 Bring down a hand and tie a roller gauze on the fetal


wrist and an assistant is asked to give traction towards
the side away from the fetal head to make the neck more
accessible & fixed.
Cont.,.,

Step 2:

Two fingers of the left hand are introduced


with palmar surface downwards and the finger
tips are to be placed on the superior surface of
the neck.
Cont….
 Step 3:

 The decapitation hook with knife is introduced flushed under


the guidance of the finger placed into the vagina the knob
pointing towards the fetal head.

 The hook is pushed above the neck and rotated to 90 degree


so as to place the knife firmly against the neck.

 The internal fingers, in the mean time, are placed on the


under surface of the neck to guard the tip of the hook.
Cont…
Step 4
 By upward and downward movements of the hook with knife ,the
vertebral column is severed.

 The rest of the soft tissue left behind may be severed by the same
instrument or by embryotomy scissors.

 The decapitation hook is pushed up and rotated to 90 degree and


then taken out under the guidance of the internal fingers.

 The decapitated head is pushed up and the trunk is delivered by


traction on the prolapsed arm.
Cont…
 Step 5:
 Delivery of the decapitated head:
 By hooking the index finger into the mouth.
 By holding the severed neck with giant vulsellum and
delivery of the head as that of after coming head in breech.
 By using forceps.

 Step 6:
 Routine exploration of the utero-vaginal canal to exclude
rupture of the uterus or any other injury.
EVISCERATION

Definition:

The operation consists in removal of


thoracic and abdominal contents piecemeal
through an opening on the thoracic or abdominal
cavity at the most accessible site.
Principle:
• To diminish the bulk of the fetus which
facilitates its extraction.
• If difficulty arises, the spine may be divided
(SPONDYLOTOMY) with embryotomy
scissors.
Indication:

• Neglected shoulder presentation with dead fetus.

• Fetal malformations ,such as fetal ascites or

hugely distended bladder or monsters.


INSTRUMENT
EMBRYOTOMY
GIANT VULSELLUM SCISSORS
CLEIDOTOMY
Definition:

The operation consist of reduction in the


bulk of the shoulder girdle by division of one or
both the clavicles.

Indications:

Dead fetus ( anencephaly excluded) with shoulder


dystocia.
Instrument

Embryotomy scissors
Procedure:

The clavicles are divided by the embryotomy


scissors or long straight scissors introduced
under the guidance of left two fingers placed
inside the vagina.
SYMPHSIOTOMY
DEFINITION:
It is the operation designed to enlarge the
pelvic capacity by dividing the symphysis
pubis.
Cont.,.,
• Conditions to be fulfilled are:
The pelvis should not be severely contracted.
Vertex must be presenting.
The FHS must be present.
Procedure:
The operation consists of dividing the
symphysis pubis strictly in the midline from
above downwards until the arcuate ligament is
cut.
The fingers of the left hand in the vagina
displaces the urethra to one side.
The baby is delivered spontaneously with
liberal episiotomy or by traction with ventouse
or forceps.
Complications:
Retropubic pain.
Osteitis pubis.
Stress urinary incontinence.
Vesicovaginal fistula (Rare).
Complications of destructive operations

• Injury to the utero-vaginal canal.

• Post partum hemorrhage.

• Shock.

• Puerperal sepsis.

• Subinvolution.

• Injury to the adjacent viscera.

• Prolonged ill health.


POST OPERATIVE CARE

• Exploration of the utero-vaginal canal must be


done.

• Self retaining Foley's catheter (3-5 days).

• Dextrose saline drip (till dehydration corrected).

• Blood transfusion ( If required).

• Ceftriaxone 1g IV infusion is given twice daily.